CNO Infection Control Guidelines PDF

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PR ACTICE STANDAR D

Infection Prevention and Control

Table of Contents Introduction

3

Standard Statements

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Application of evidence-based measures

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Application of professional judgment

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Risk reduction

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Communication

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Maintaining a Quality Practice Setting

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Case Scenarios

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Appendix

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Glossary of Clinical Terms

11

References

12

OUR MISSION is to protect the public’s right to quality nursing services by providing leadership to the nursing profession in self-regulation. OUR VISION is excellence in nursing practice everywhere in Ontario.

Infection Prevention and Control

Pub. No. 41002

ISBN 1-897074-32-8 Copyright © College of Nurses of Ontario, 2009. Commercial or for-profit redistribution of this document in part or in whole is prohibited except with the written consent of CNO. T his document may be reproduced in part or in whole for personal or educational use without permission, provided that:

or with the endorsement of, CNO. First published February 1996 as Infection Control Guidelines (ISBN 1-894557-33-6) Reprinted January 2000, October 2000, revised for Web June 2003, reprinted January 2004 as Infection Control (ISBN 1-894557-44-1)

or toll-free in Ontario at 1 800 387-5526. College of Nurses of Ontario

Ce fascicule existe en français sous le titre : La prévention des infections , n° 51002

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Nursing standards are expectations that contribute to public protection. They inform nurses of their accountabilities and the public of what to expect of nurses. Standards apply to all nurses regardless of their role, job description or area of practice. — College of Nurses of Ontario

Introduction Ensuring the use of safe, effective and ethical infection prevention and control measures is an important component of nursing care. This practice standard is evidence-based and outlines practice expectations for all nurses¹ in all roles and practice settings. A practice standard is an authoritative statement from the College of Nurses of Ontario (the College) that sets out the professional basis of nursing practice. All standards provide a guide to the knowledge, skills, judgment and attitudes that are needed to practise safely. They describe what each nurse is accountable and responsible for in practice.

All nurses, in all roles and settings, can demonstrate leadership in infection prevention and control by using their knowledge, skill and judgment to initiate appropriate and immediate infection control procedures. This practice standard describes a nurse’s role in infection prevention and control. There are six sections: standard statements and indicators that outline the basic expectations for nurses, a review of quality practice settings, case scenarios that illustrate how the standards can be applied, an appendix on infection transmission and management, a glossary of clinical terms and a reference list. Q. What is the simplest and most important practice a nurse can do to reduce contamination and spread of infection?

Nurses are expected to be aware of College standards and relevant governmental directives concerning infection prevention and control practices. Public protection is achieved when nurses practise according to the standards. Knowledge of clinical infection control practices is continually growing and changing. While the principles of infection control (prevention, transmission and control) do not change, specific clinical practices may evolve as a result of new evidence. For this reason, this practice standard provides broad statements and does not include specific clinical practice information. A nurse is expected to consult appropriate resources for clinical advice and access resources in a timely manner. These resources may include, but are not limited to, an infection control practitioner, relevant nursing resources and guidelines from Health Canada and the Ministry of Health and Long-Term Care.

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A. Proper hand hygiene is the single mostimportant infection prevention and control practice.

In this document, nurse refers to a Registered Practical Nurse (RPN), Registered Nurse (RN) and Nurse Practitioner (NP).

College of Nurses of Ontario Practice Standard: Infection Prevention and Control

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PR ACTICE STANDAR D

Standard Statements Application of evidence-based measures Nurses understand and apply evidence-based measures to prevent and control transmission of micro-organisms that are likely to cause infection.

Indicators The nurse meets the standard by: adhering to appropriate hand hygiene protocols; using a systematic approach to care (for example, nursing process) based on current infection control principles and research; knowing her/his personal immunization status relevant to the practice setting and taking appropriate action to ensure client protection; knowing a client’s immunization status relevant to the practice setting and taking appropriate action to ensure protection of clients, others and self (for example, information, referral, isolation, etc.); taking all measures necessary to prevent the transmission of infection from the nurse to client(s) or other health care providers; seeking advice from her/his primary health care ■

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provider regarding the potential for transmission to clients or other health care providers when the nurse has a potentially transmissible disease; maintaining competence in infection control practices by accessing appropriate resources (for example, infection control practitioners, current research); taking appropriate action when a co-worker has a potentially transmissible disease; advocating for an environment and equipment that reduce the risk for disease transmission; and advocating for the establishment of and compliance with infection control policies relevant to the practice setting.

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Application of professional judgment Nurses exercise professional judgment relevant to each client situation and infection prevention and control practices.

Indicators The nurse meets the standard by: assessing situations for potential or actual infectious disease transmission; selecting and using the appropriate prevention measures when micro-organisms are likely to come into contact with the nurse’s skin, mucous membranes or clothing; modifying her/his practice appropriately when there is a risk of transmitting a disease to clients or other health care providers;

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College of Nurses of Ontario Practice Standard: Infection Prevention and Control

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selecting, in collaboration with the health care team, the appropriate agency, manufacturer and government guidelines regarding the use and fit of personal protective equipment (PPE); and advocating for change when agency, manufacturer or government guidelines do not meet infection control requirements regarding the appropriate use and fit of PPE.

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Risk reduction Nurses reduce the risk to self and others by appropriately handling, cleaning and disposing of materials and equipment.

Indicators The nurse meets the standard by: participating in education on the use of safer medical devices and work practices relevant to the practice setting; adhering to best practices or manufacturer’s guidelines on the cleaning, disinfecting and disposal of wastes or hazardous material; using safety devices (for example, needle-less IV systems, sharps disposal containers, disposable stethoscopes, closed laundry systems) when available;

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following established guidelines when disposing of biomedical waste; identifying hazards and the potential for injury; intervening and providing appropriate care when an exposure has occurred to client(s), self or another health care provider; reporting a breach in infection control technique and taking action to limit damage; advocating for safety devices; and advocating for changes in practice based on an evaluation or evidence (for example, single-use items).

Communication Nurses use appropriate and timely communication strategies with clients and their significant others, the health care team and the community when discussing infection prevention and control issues.

Indicators The nurse meets the standard by: incorporating the psychosocial needs of clients and their significant others into the plan of care; using appropriate teaching strategies to communicate health information to clients; developing creative or innovative communication strategies to overcome factors that could inhibit the

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therapeutic nurse-client relationship (for example, isolation, masks); maintaining open communication with the health care team, including support staff; communicating safety concerns to the appropriate authority; and advocating for communication systems that protect client confidentiality.

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Maintaining a Quality Practice Setting Quality nursing care includes safe and effective infection prevention and control practices. As partners, employers and nurses have a shared responsibility to create environments that support quality practice. The College encourages employers and nurses to use the following strategies to develop and maintain a quality practice setting that supports nurses in providing safe, effective and ethical care. Care delivery processes Care delivery processes support the delivery of nursing care/services related to infection prevention and control. Possible strategies include: ensuring there is a process to make assignment decisions that recognize work load, knowledge of infectious diseases, and infection prevention and control processes; providing accessible, current infection control resources; evaluating infection control measures; consulting with nurses to identify system problems; ensuring a client-centred focus in relation to infection prevention and control processes; and supporting nurses to intervene when client safety is threatened.

Facilities and equipment The physical environment and access to equipment can support and increase the efficiency and effectiveness of infection prevention and control practices. Possible strategies include: ensuring supplies and equipment are available to support staff in infection prevention and control practices; and involving nurses in designing and implementing changes in infection prevention and control systems. ■

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Leadership Leadership is the process of supporting others to improve client care and services by promoting professional practice.

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Communication systems Communication systems support information sharing and decision-making about client care and services. Possible strategies include: implementing a system to promote information sharing about infection prevention and control among all health care team members; developing and maintaining effective conflict management processes; and providing opportunities for critical incident debriefing. ■

Possible strategies include: involving nurses in planning, implementing and evaluating infection control processes; modelling the correct and appropriate use of personal protective equipment; designating a person to ensure that evidencebased infection prevention and control policies and procedures exist; and providing appropriate educational resources. ■

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Organizational supports Organizations support infection prevention and control practices by using appropriate structures and processes. Possible strategies include: ensuring that infection control policies and procedures are up-to-date; and implementing health and safety programs for all staff, including programs for surveillance, treatment for contacts, screening and immunization. ■

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College of Nurses of Ontario Practice Standard: Infection Prevention and Control

Professional development systems Professional development includes orientation and education related to infection prevention and control.

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Possible strategies include: providing education on the correct use of equipment; and developing and using effective methods to inform nurses about new developments in infection prevention and control practices. ■

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Response systems to external demands The timely way in which an organization responds to changes in legislation, consumer demands, health care trends and government directives will impact the nurse’s ability to provide care. Possible strategies include: establishing policies to reflect government directives related to infection prevention control; and ensuring resources are available to follow emergency directives. ■

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Case Scenarios These case scenarios illustrate how the principles of infection prevention and control and the standard statements in this document can be applied. They are not all-inclusive, and clinical advice should be sought from appropriate resources.

Scenario 1 Fatima, a home-visiting nurse, has a client with an open draining wound on her abdomen. A recent culture of the wound found the micro-organism Methicillin-resistant Staphylococcus aureus (MRSA).

control practice. The educator highlighted the importance of using hand rinse stations located throughout the ER.

Scenario 3 Shawn is a nurse in a long-term care facility and is assigned to a client with a respiratory infection. The client is symptomatic and requires various degrees of nursing care. Shawn meets the standards and reduces the risk to the client, himself and others by: knowing that respiratory illnesses are transferred through airborne or droplet mechanisms; selecting the appropriate precautions; being sensitive to how the infection control barriers affect communication between him and his client; washing his hands before and after using personal protective equipment; adhering to hospital policies and manufacturer guidelines for the re-processing of equipment; ensuring any equipment removed from the client’s room is cleaned with an appropriate disinfectant; and advocating for equipment that remains within the client’s isolation room (not unit shared) or singleuse items (for example, disposable stethoscopes). ■

Fatima meets the standards and reduces the risk to her client, herself and others by: identifying the mode of transmission; applying hand hygiene principles; choosing the appropriate barrier(s) to prevent and control the transmission of the micro-organism; applying the principles for safely handling, cleaning and disposing of materials and equipment; and communicating effectively according to the College’s Therapeutic Nurse-Client Relationship, Revised 2006 practice standard. ■ ■ ■

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Scenario 2 A client enters a hospital emergency department complaining of nausea, vomiting, diarrhea and a low-grade fever. As Lisa, an ER nurse, begins to assess the client, he has an episode of diarrhea. In keeping with the hospital’s protocol on infection control, Lisa puts on a pair of gloves and a gown before providing personal care and changing the bed linen. The ER is busy, and she finishes with the client by quickly disposing of the soiled laundry and removing her gloves and gown. She then begins to assess the vital signs of her next client. Lisa does not wash her hands before performing her assessment. By not washing her hands, Lisa potentially transmitted micro-organisms from one client to another, and breached the facility’s protocols on infection control. The nurse educator, who observed Lisa’s actions, reinforced that hand hygiene is the single most-important infection prevention and

College of Nurses of Ontario Practice Standard: Infection Prevention and Control

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Appendix

There are five main modes of transmission.

This section provides information about general infection control practices. For more information, see References on page 12 and/or consult an infection control practitioner.

1. Contact transmission Direct contact transmission involves contact between the infectious agent and the susceptible host.

Transmission of infection The spread of infection requires an infectious agent — a pathogen that has the potential to cause infection. The pathogen may be viral, bacterial, fungal or parasitic. The infectious agent needs a reservoir where it can live, grow and reproduce. Reservoirs are warm, moist places. Humans, animals or the inanimate environment (for example, water, food, soil and soiled medical equipment) are potential reservoirs. Human reservoirs include individuals with an acute infectious disease, and those who are in the incubation period of the disease and asymptomatic carriers. The transmission of infection also requires a susceptible host. Susceptibility to an infectious agent varies among individuals. Factors that influence a person’s susceptibility include age; general physical, mental and emotional health; the amount and duration of exposure to the agent; and the immune status and inherent susceptibility of the individual. Factors such as a chronic debilitating disease, shock, coma, traumatic injury, surgical procedures or treatment with irradiation or immunosuppressive agents increase a person’s susceptibility to infection. How the infectious agent is transmitted from the reservoir to the susceptible host is called the mode of transmission. Transfer requires a route for the infectious agent to exit the reservoir (a portal of exit), a mode of travel to the susceptible host (a mode of transmission) and a route to enter the susceptible host (a portal of entry). An infectious agent can exit the reservoir and enter the host through various body systems (for example, respiratory, gastrointestinal, genitourinary tracts, skin lesions) and through mucous membranes.

Indirect contact transmission involves contact between a susceptible host and a contaminated intermediate object such as a needle, instrument or other equipment. 2. Droplet transmission Droplet transmission involves contact of the conjunctivae or mucous membranes of the nose or mouth of a susceptible host with large particle droplets (larger than five microns) that contain an infectious agent. Droplets are released through talking, coughing or sneezing, and during procedures such as suctioning and bronchoscopy. Large particle droplets do not remain suspended in the air and generally travel less than one metre through the air. 3. Vehicle transmission Food, water or medication contaminated with an infectious agent can act as a vehicle for transmission when consumed. Contaminated instruments or devices that come in contact with body tissue or the vascular system can also act as a vehicle for transmission. 4. Airborne transmission Small particle residu...